With the festive season approaching, we will soon be giving lifestyle advice and prescribing protein pump inhibitors (PPIs) to some of our more sociable patients to treat the dyspepsia caused by a long round of office parties.
However, for many patients heartburn has to be dealt with on a daily basis.
Effective treatment is available, but at a cost. NICE estimate that drugs to treat dyspepsia, and endoscopies, amount to £600 million per year, while OTC indigestion remedies cost the public a further £100 million.
Who gets heartburn?
Heartburn is the main symptom of gastro-oesophageal reflux disease (GORD), which is estimated to affect about 30 per cent of the UK population. Causes of GORD include obesity, pregnancy, high fat intake, alcohol, drugs including NSAIDs and hiatus hernia.
Sliding hiatus hernia is the most common type, and is found on X-ray in more than 40 per cent of the US population. Not all patients with hiatus hernia are symptomatic.
In patients with sliding hiatus hernia, the gastro-oesophageal junction lies above the diaphragm, allowing stomach contents to pass into the lower oesophagus.
In patients without hiatus hernia, the fault appears to lie in the gastro-oesophageal sphincter.
GORD can also cause chronic cough. It is one of the first conditions respiratory and ENT specialists consider when a patient presents with these complaints.
When oesophageal pain, rather than reflux, is a predominant symptom, it can be difficult to differentiate GORD and angina.
Modern management
Heartburn is a common presenting complaint, and a careful history is essential to detect patients who may have serious disease.
Evidence shows that, in the absence of alarm symptoms such as weight-loss or vomiting, it is reasonable to manage these patients in the initial stages without referral.
Lifestyle and dietary advice should be given and medication reviewed for potential causes, such as anti-inflammatory medication, calcium-channel blockers, nitrates, theophylline, bisphosphonates or steroids. Helicobacter pylori testing is recommended for investigation of dyspepsia.
Following this, a trial of PPI therapy should be given in full dosage for one or two months, and the patient reviewed. If there is improvement, the dosage of PPI can be lowered to maintenance.
If the patient fails to respond, the PPI dosage can be doubled for one month. If this is also unsuccessful, an H2 blocker such as ranitidine or a pro- kinetic agent such as metoclopramide can be added for one month.
Intractable heartburn may also require a referral and endoscopy.
H pylori and GORD
The general consensus is that H pylori is somewhat protective because the bacterium inhibits production of acid in the gastric antrum. Treating H pylori therefore may exacerbate the problem.
However, recommendations are that it should still be eradicated because of its association with peptic ulcer and gastric cancer, and because any worsening of symptoms should respond to a PPI.
Barrett's oesophagus
Barrett's oesophagus is defined as metaplasia of the squamous epithelium of the lower oesophagus into columnar epithelium. Long segment disease is involvement of over 3cm and is found in 1.4 per cent of endoscopies.
It is thought to be associated with GORD, and has malignant potential estimated at about 1 per cent per year.
Surveillance endoscopy should be arranged for these patients at regular intervals. Short segment disease does not appear to be associated with malignancy.
Operative treatment
Standard operative treatment procedure is the Nissen fundoplication, in which the top of the stomach is wrapped around the distal oesophagus, creating a competent 'valve'. It can now be performed laparoscopically, with a 90 per cent success rate.
Newer treatments include endoluminal gastroplication, which is performed as an outpatient. Using an endoscope, the lower oesophagus is visualised and small pleats are sewn so as to narrow the lumen.
Dr Glenesk is a GP in Aberdeen
References
- NICE - Dyspepsia: Managing dyspepsia in adults in primary care (2004)
- SIGN - Dyspepsia (guideline 68, 2003)
